Lau J Y, Lo S Y, Ng E K, Lee D W, Lam Y H, Chung S C
Department of Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong, New Territories.
Am J Surg. 1998 Apr;175(4):325-7. doi: 10.1016/s0002-9610(98)00006-3.
In patients with peritonitis from perforated peptic ulcers, we compared acute stress responses, endotoxemia, and bacteremia following laparoscopic or open surgery.
Consecutive patients with peritonitis from perforated peptic ulcers were randomized to receive laparoscopic sutured or open omental repair. Undiluted peritoneal fluid was obtained at surgery for quantitative bacterial and endotoxin (Limulus Amoebocyte Lysate) assay. Serial blood samples were taken at 0, 30, 60, 90, 120, and 180 minutes, and at 12, 24, 48, 72, and 120 hours for determinations of quantitative bacterial and endotoxin assays, interleukin-6 (IL-6), C-reactive protein (CRP), and cortisol.
Twenty-two patients were randomized: laparoscopy group (n = 12), open repair group (n = 10). Conversions were required in 3 patients assigned to laparoscopy, leaving 9 patients for analysis. The two groups were comparable in their demographic data, median duration of perforation (13.5 hours versus 10 hours), severity of peritoneal contamination as indicated by viable bacterial count (5.9 x 102 versus 1.5 x 10(2) colony forming unit/mL) and endotoxin concentration in peritoneal fluid (27.2 versus 24.6 EU/mL). No significant endotoxemia or bacteremia was detected in these patients. Median interleukin-6 was highest at 0 hour (1520 versus 962 pg/mL) and fell rapidly following surgery. C-reactive protein peaked at 24 hours and plateaued thereafter. Cortisol was highest intraoperatively and fell thereafter. No difference was noted between the two treatment groups with respect to these inflammatory markers (IL-6 P = 0.19, CRP P = 0.14, cortisol P = 0.56, multivariate analysis of variance).
Endotoxemia and bacteremia are insignificant in most patients with perforated peptic ulcers. In patients with perforated peptic ulcers, laparoscopic patch repair does not reduce acute stress responses when compared with open surgery.
在患有消化性溃疡穿孔所致腹膜炎的患者中，我们比较了腹腔镜手术或开放手术后的急性应激反应、内毒素血症和菌血症。
将连续的消化性溃疡穿孔所致腹膜炎患者随机分为接受腹腔镜缝合或开放大网膜修补术两组。手术时获取未稀释的腹腔积液用于定量细菌和内毒素（鲎试剂）检测。在0、30、60、90、120和180分钟以及12、24、48、72和120小时采集系列血样，用于定量细菌和内毒素检测、白细胞介素-6（IL-6）、C反应蛋白（CRP）和皮质醇的测定。
22例患者被随机分组：腹腔镜组（n = 12），开放修补组（n = 10）。3例分配至腹腔镜组的患者需要中转开腹，最终9例患者纳入分析。两组在人口统计学数据、穿孔中位持续时间（13.5小时对10小时）、腹腔污染严重程度（以活菌计数表示，5.9×10²对1.5×10²菌落形成单位/mL）以及腹腔积液内毒素浓度（27.2对24.6 EU/mL）方面具有可比性。这些患者中未检测到明显的内毒素血症或菌血症。白细胞介素-6中位数在0小时最高（1520对962 pg/mL），术后迅速下降。C反应蛋白在24小时达到峰值，此后趋于平稳。皮质醇在术中最高，此后下降。在这些炎症标志物方面，两个治疗组之间未观察到差异（IL-6 P = 0.19，CRP P = 0.14，皮质醇P = 0.56，多因素方差分析）。
在大多数消化性溃疡穿孔患者中，内毒素血症和菌血症并不显著。在消化性溃疡穿孔患者中，与开放手术相比，腹腔镜补片修补术并不能减轻急性应激反应。
